Do stimulants, such as Ritalin (methylphenidate) or amphetamines, worsen tinnitus in adults and children with Attention Deficit Hyperactivity Disorder (ADHD)?

Do Stimulants Worsen Tinnitus?

There is no evidence that stimulants used for ADHD treatment worsen tinnitus, and tinnitus is not listed as a contraindication or significant concern in major ADHD treatment guidelines. 1

Evidence from ADHD Treatment Guidelines

The American Academy of Child and Adolescent Psychiatry's comprehensive practice parameters for stimulant medications do not identify tinnitus as a contraindication, precaution, or adverse effect of concern when prescribing methylphenidate, dextroamphetamine, or mixed amphetamine salts. 1

The guideline explicitly lists the actual contraindications for stimulant use, which include:

• Concomitant MAO inhibitor use (risk of hypertensive crisis) 1
• Active psychosis or schizophrenia (stimulants are psychotomimetic) 1
• Glaucoma (may increase intraocular pressure) 1
• Preexisting liver disease for pemoline 1

Notably absent from this list is any mention of tinnitus or auditory concerns. 1

Isolated Case Report of Hearing Loss

One case report from 2014 described an 8-year-old child who developed sudden hearing loss, tinnitus, balance problems, and ear fullness after the first dose of methylphenidate. 2 However, this represents an extremely rare event—a single case among millions of patients treated with stimulants over decades. 2

Critical Limitations of This Case Report:

• This is a single case report, the weakest form of medical evidence 2
• The temporal association does not prove causation 2
• No mechanism of action has been established linking stimulants to tinnitus 2
• This finding has not been replicated in any controlled studies or large observational cohorts 2
• Major systematic reviews of amphetamines and stimulants do not identify tinnitus as a recognized adverse effect 3

What Actually Causes Tinnitus in Psychiatric Patients

Antidepressants, not stimulants, are the psychiatric medications most commonly associated with tinnitus. 4 Antidepressants can both cause tinnitus as a side effect and potentially treat it in certain patients, particularly those with depression or anxiety. 4

Clinical Recommendation

Proceed with standard stimulant treatment for ADHD without specific concern for tinnitus worsening. 1 If a patient with pre-existing tinnitus reports worsening after starting stimulants, consider alternative explanations first (stress, anxiety, sleep deprivation—all of which can be affected by untreated ADHD or stimulant side effects). 1

Monitor for the established common side effects of stimulants:

• Appetite suppression 5
• Abdominal pain 5
• Headaches 5
• Sleep disturbance 5
• Mild increases in heart rate and blood pressure 5

If genuine concern exists about the single case report, non-stimulant alternatives like atomoxetine have no association with auditory symptoms and represent a viable alternative. 6, 7